Vol. 124 May 1, 2015 Why Can’t Physicians Prognose Better?

May 1, 2015

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“It’s tough to make predictions, especially about the future.
-Yogi Berra

 

In 2013 seven Italian scientists were convicted of manslaughter and sentenced to six years in prison for not predicting an earthquake. The group of them, the Major Risks Committee (MRC), reassured the populace of L’Aguila which had just experienced a “swarm” (a geo-seismic term) of small tremors that the likelihood of a major earthquake was so small that “no action was needed”. Three weeks later a 6.3 earthquake in the region killed 309 people. Relatives of 29 of the fatalities pressed charges.  Such an outcome demonstrates the dangers of declaring the “unlikely” as “impossible”. In our medical world of close to “zero tolerance for risk” and a “demand for certainty” the risk of incorrect predictions can be daunting.

With all our training, scientific knowledge, and experience you would think that  physicians would be pretty good at predicting survival, aka “making a prognosis”. Several comparison studies have shown that physicians are not really any better than their patients in estimating survival time. Prognosis reliability does vary by diagnosis type and “closeness to the end” (in retrospect, of course, because we can never be sure that we are near the end until the end is here). For example, BOTH physicians and patients are overly optimistic in predicting the time left for lung cancer patients. Physicians’ prognosis of death are correct nearly 90% of the time in non-cancer nursing home patients when death occurs within 7 days later. That percentage drops to 13-16% when actual death occurs 3 – 6 weeks later.  Physicians also tend to be even more overly optimistic than patients about the expected quality of life near the end.

One Harvard explanation of this is as follows:
“Similar to other forecasting experts, physicians face different [non-monetary] costs depending on whether their best forecasts prove to be an overestimate or an underestimate of the true probabilities of an event. We provide the first empirical characterization of physicians loss functions. We find that even the physicians subjective belief distributions over outcomes are not well calibrated, with the loss characterized by asymmetry in favor of over-predicting patients’ survival. We show that the physicians’ bias is further increased by (1) reduction of the belief distributions to point forecasts, (2) communication of the forecast to the patient, and (3) physicians own past experience and reputation.”
 In other words, a physician’s gut feeling is often just “guesswork.”

All of us have heard the story of a patient who was told that he had “a year to live” and the patient went on fishing for cod or bluefish or whatever for another six years. Some of us have suffered the opposite experience. I can not forget the infant boy we diagnosed with hemophilia in the 1970’s and reassured the parents that we, along with modern medical science, could promise him a near-normal life with the use of factor VIII infusions. The patient enjoyed a healthy six years and even learned to infuse himself when only 8 years old. He became one of the first to contract HIV from factor VIII, and he died a teen ager with resistant, intractable pneumonia; a personally wrenching failure of a promise (prognosis) made by modern medicine. Technology and research have corrected that cause, but the memory lingers on.

Studies to identify specific characteristics or elements that could be used to more accurately state a survival prognosis have revealed a mixed bag. None is reliable enough for general clinical use.  If we did have a scientific consensus then the often complex, complicated negotiations of end-of-life care would be a lot easier for both physicians and patients and their families. It would perhaps be less costly for Medicare also.

Of course, despite the decades of study and technological advances we are no better at predicting the actual day a baby is born either … especially within a week of the actual delivery. At least we have “the nine-month consensus” to limit our predictive unreliability for birth dates.


Vol. 76 October 15, 2012 The High Life and A Good Death

October 15, 2012

“Hey, D-u-u-de!”
-The Big Lebowski, 1998
.

“She had a good death.”
-traditional Irish Catholic saying

On Nov. 6 Massachusetts will vote on two medically related referendum questions: Medical Marijuana and Physician-Assisted Suicide.  In the spirit of transparency and to offer a break from mind-numbing candidate debates, I offer this short commentary on the two…and a proposal to combine them.

Ballot Question 3: “Do you approve of  a law that would eliminate state and criminal and civil penalties related to the medical use of marijuana allowing certain patients to obtain by a physician’s prescription marijuana  produced and distributed by new state-regulated centers,or, in specific hardship cases, to grow marijuana for their own use?”

Short name: Medical Use of Marijuana
A better name: “Marijuana by request of certain consenting adults”
Street spin: Very positive

Who’s against it:  AMA and Mass Medical Society – Concerns: “The slippery slope” What’s next? Legalization of marijuana?
Local police very concerned about increased cost of investigating and enforcing multiple backyard plots.
Anti-Smoking organizations.
When Congress passed the Marijuana Tax Act in 1937 making it illegal for anyone, including doctors, “to move cannabis without proper documentation”, the AMA opposed the bill!  (1)

Who’s for it: Lester Grinspoon, MD (2), most people under 50, and anybody who answers to the name, “Dude.”

What does the data show: Illegal marijuana is currently a bigger cash crop in Kentucky than tobacco. There are more medical marijuana shops in Denver than Starbucks. It IS (is NOT) a “gateway” drug…take your pick of positions…data supports both. 17 states have legalized medical marijuana.

Worst case scenario: Prescriptions for marijuana surpass number of prescriptions for SSRIs, Ritalin, and Oxycodone… or maybe that would be an improvement?

Economic implications: Could be a significant economic stimulus… in Kentucky, at least. The price of medical marijuana in California and Colorado is half the price that illegal marijuana was.

Possible future headline: “Legal Marijuana Aids Economic Recovery, Second Only to Casino Development.”

Ballot Question 2: “Do you approve of a law that would allow a physician licensed in Massachusetts to prescribe medication, at the request of a terminally ill patient meeting certain conditions, to end that person’s life?”

Short name: Physician Assisted Suicide
A better name: “Death with Dignity by request of certain consenting adults.”
Street spin: How can anything be positive about the term “suicide”? “Physician-assisted dying” is closer to the reality.

Who’s against it: AMA and Mass Medical Society; incompatible with the “curative and healer” roles of physicians – Concerns: “The slippery slope” What’s next? Lethal injections for psoriasis?
We can’t always be certain of which months are “the last 6 of my life”, but about 83% of hospice patients were right in one study.
Who’s for it: Many members of Ethics Committees in acute care hospitals who have helped patients and families endure prolonged, high-tech deaths.

What does the data show: Since its passage in 1997 less than 100 Oregon patients per year have requested end-of-life medications. In 2011 only about one-half of the people getting such prescriptions in Oregon actually took the pills. (Maybe it IS a question of patients’ desire for lost autonomy and control) In Oregon 90% of requesting patients were enrolled in a hospice program and nearly 90% had cancer.

Worst case scenario: Patients may desire more power over their medical life as well as their medical death.

Economic implications: May have positive impact on medical care costs if people choose not to go into hospitals and be admitted to ICUs in the last 6 months of their life.

Possible future headline: “AMA Admits Physicians Can’t Cure Everyone, Calls For More Dignity In Dying”

Proposed Ballot Question 4: “Do you approve of a law that would allow physicians to prescribe marijuana to end the life of a terminally ill patient?”

Short name: “Physician Assisted Dying by Marijuana”.
Street spin: It will never happen. Marijuana is the ONE drug that can NOT cause a lethal overdose (unlike alcohol, aspirin, and the others). Dr. Grinspoon described it as “remarkably non-toxic”. He initiated his intensive research into the effects of marijuana when he observed its benefits in his son undergoing chemotherapy. (His wife got the marijuana for Danny in the parking lot of a local high school because Dr. Grinspoon was initially so skeptical of its effects).(1)

References:
1. “Where’s the Pipe?”, Casey Lyons, Boston Magazine, October 2012
2. Marijuana Reconsidered, Lester Grinspoon,MD; 1971 and Marijuana:The Forbidden Medicine; 1997


Vol. 70 July 1, 2012 There’s a New “F” Word in Town

July 1, 2012

Care is never futile, but medical interventions sometimes are. (1)

Ten years ago our community hospital’s Ethics Committee spent a lot of time trying to reach a consensus on the meaning and implications of the “F” word. Our context almost always was the ethical dilemmas of end-of-life decisions, renal dialysis, continued ICU care, and mechanical ventilation support. Was it ethical to continue renal dialysis on the Jamaican woman when we considered dialysis to be a medically futile treatment or should we send her back to her country as she requested where it ws not avialable?  Should the young man comatose after being struck by lightening be continued on ventilation support when any further treatment appeared to be futile?

At that time our futility discussions focused primarily on patient or family “demands” to continue expensive therapy with little hope of real benefit to the patient. Our discussions closely mirrored articles in the medical and popular literature at the time, and, likewise, did not result in a consensus of the definition of futility. At a 2003 meeting our Ethics Committee reviewed four different kinds of failed attempts to define futility, 1) by reaching a medical consensus, 2) by using empirical data, 3) accepting patient-defined futility, and 4) accepting physician-defined futility. We could only conclude that sometimes all we could say was, “We feel that further care is futile.” There are three “F” words in that simple sentence. Our attremptd emphasis on feelings never really helped in making the message any easier to deliver, understand, or accept. Trying to substitute one “F” word for another never really stuck to the wall.

With the passage of the Affordable Care Act the context of “futility” discussions has broadened considerably as legislators, insurance companies, and providers struggle with the central problem of how to pay for universal access to all kinds of medical care without using the “R” word.  The most recent example of that changing context is an essay by a MD lawyer advocating the new “F” word of “Frugality” (2).

The author argues that even if and when we reduce medical care costs by eliminating the estimated 30% spent on “wasted or ineffective measures” (3) we will still be facing the apparently inexorable annual rise of medical care costs “unless we start saying no to some beneficial care”. He does not think that the Independent Payment Advisory Board (IPAB) with the authority to change Medicare payment policies, or the Medicare “luxury tax” on Cadillac employment-based health insurance, or the current incentives for new Accountable Care Organizations and insurance companies will be enough to slow the rise of medical care costs. The new “Frugality” will only be achieved by more selective adoption of new technology. This means that after we say “no” to non-beneficial technology “we will need to say ‘no’ to some potentially beneficial new technologies because of imperfect data about clinical effectiveness”.

Daniel Callahan, President Emeritus of the Hasting Centers and one of our most respected Medical Ethics gurus, made the same argument in his 2009 book, Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System (4) His opinion is that multiple studies in the 1980s-1900s comparing the cost reduction effects of regulation vs. competition are inconclusive, and that there is little evidence that the “business model” of competition works in health care. His solution to reducing medical care costs is to restrict the unbridled introduction of new technology. In his view new technology often raises the cost of medical care without improving health. The answer is rigorous assessment of new technology (both drugs and devices). “Technology assessment must COMMAND, not just COMMEND.”

“Futility” is such a negative, dead-end word. It is the end. “There is nothing more we can do.” It is colored by end-of-life issues, discussion of which are necessary and important, but which have become politicized.

“Frugality” implies a positive value, a process. “Thrifty” made it to the Boy Scout pledge, but it could have been “frugality” just as easily.
Lets hope that “frugality” sticks to the wall.
We shall see.

References:
1.Poncy M. Ethics and futile care. Program and abstracts of the National Conference of Gerontological Nurse Practitioners 25th Annual Meeting; September 27-October 1, 2006; Ponte Vedra Beach, Florida.
2. Beyond the “R Word”? Medicine’s New Frugality, NEJM 366;21, G. Bloche, pg. 1951
3. Implications of Regional Variations in Medicare Spending, Ann Int Med 2003;138, Winneberg, et al., pg. 288-298
4. Princeton University Press, 267 pages


Vol. 53 October 15, 2011 The Heart of the Matter

October 14, 2011

Imagine that you are over 65 years old and you have a failing heart. Your doctor tells you that you are at “maximum medical treatment” and are not eligible for a heart transplant because of your age and other medical conditions.  Then the doctor mentions that a pump could be implanted in your body to help your heart pump more blood; a left ventricular assist device or LVAD.

Imagine a small device put into your chest during open heart surgery that could help you pump enough blood around so that some of your old energy would return and you could resume some, but not all, of your usual activities.

Imagine that Medicare would pay for the operation, device, and medical follow-up. Then try to imagine what the $228,039,342 Medicare paid for about 1500 of these operations would look like if spread out on a table in hundred-dollar bills.

Imagine what it would be like to be one of the 55% (815) of patients who survived the operation and left the hospital alive after receiving this pump. Imagine how even happier you would be if you were one of the 43%  (350) discharged alive who was still alive 2 years later. Imagine your relief when Medicare pays the average $1,000 a day hospital rate for the 56% of pump recipients who have to be rehospitalized at least once in the 6 months after implantation.

Imagine your perplexing thoughts when a statistician tells you that your life extension cost about $60,057 “per quality-adjusted life-year”.

Imagine that your psyche and your family can handle the burdens of multiple medical visits, utter dependence on the infallibility of a medical device, 24/7 family care and vigilance, strict adherence to medication regimens, worries about medical and financial complications, and alteration of body image perceptions that can lead to depression and anxiety.

Imagine how your life might actually end. If you turn off the pump it is suicide. If your doctor or family member turns off the pump it is either euthanasia, assisted suicide, or ethical withdrawal of therapy depending on the status of your permission (and maybe the State you are in).  Perhaps you will develop a new fatal condition from which you will die with the pump running. Imagine if you lived long enough to require a pump replacement.

Imagine that part of the pre-operative process before the pump is implanted is a detailed discussion with your physician (and your family hopefully) about how and when YOU would want the pump turned off.

NOW … IMAGINE THAT YOU ARE DICK CHENEY. *

Then imagine how a “rationing” process to cut medical care costs under Medicare might work in this situation.

Imagine how it might work if you were the patient rather than Mr. Cheney.

Blogs have already appeared making the argument that Steve Jobs would not have lived his “extra” two years with a liver transplant under U.K. or Canadian health systems.

Medical ethics are about “where you draw the line”. Remember that in the beginning of this scenario your doctor said you were “ineligible” for a heart transplant. That was a drawn line, a rationing decision. Our current dilemma and sometimes heated discussion is really about WHO draws the line. (Medicare, Medicaid, private insurance or pharmaceutical company, Congress, professional specialty societies, health care lobbyists, medical ethics committees, Comparative Effectiveness Research in the U.S., NICE in the U.K., individual physicians and patients, or God)

*shamelessly copied from Matthew McConaughey’s dramatic closing speech to the jury
saving Samuel L. Jackson’s life in A Time To Kill  by John Grisham.

References;
Journal of Medical Ethics, Spring 2011, Vol.18, issue 2, published by Lahey Clinic; LVADs as destination therapy: difficult ethical decisions.

Taming the Beloved Beast: How Medical Technology Costs are Destroying Our Health Care System, Daniel Callahan, 2009, Princeton  University Press


Vol.45 May 15, 2011 Surprising Medical Fun Facts

May 15, 2011

“Scientists constantly change their minds.
Science is not about immutable laws but provisional
explanationsthat get revised when a better one comes along.
Scientists’ readiness to change their beliefs to align with data
is a source of great strength, not weakness.”
– Daniel Willingham, Prof. of Psychology, Univ. of Virginia
in Scientific American May 2011


Does cranberry juice prevent bladder infections?
NO,
 according to a study of 155 healthy college women in Michigan (the state that produces the most cranberries) who drank two glasses a day of cranberry juice for 6 months after having a bladder infection. The cranberry juice swillers had a recurrence rate of 19% which was lower than the expected recurrence rate of 30%, BUT the control group that drank two glasses a day of a cranberry-like placebo also had a lower than expected recurrence rate at 15%. (1) The study was done to find out if proanthocyanidin, the suspected preventative ingredient in cranberry juice, really worked. The problem is that “tiny little berry that continues to defy science” contains over 200 active substances and several organic acids.Proanthocyanide apparently is not THE one.


Walk fast and carry a big stick .
A study of 35,000 community-dwelling adults with a mean age of 74 showed that life expectancy increased about 12% for each 4 inches per second faster one could walk. A threshold for “higher risk of early mortality” is suggested as “being unable to walk 20 feet in 10 seconds”. (2) In a separate study of 2900 community-dwelling Australian men, 40% of those who were 70-74 years old  reported being sexually active.  43% of those reported having sex less than desired. (3)

The umpires refused to be tested.
Dr. Daniel Laby, a Harvard Professor of Ophthalmology and eye doctor to the Red Sox, reports that the average baseball player’s vision is 20-12. That means they can see at 20 feet what we can’t see until its 12 feet away. The normal standard is 20-20, of course, and the very best a human eye can see is 20-8. He states that seeing the seams on the moving ball is one of the key factors in successful hitting. Dr. Laby offered Major League Baseball the same service for the umpires.  MLB did not respond. (4)

Are they sleeping on the job?
31% of employed Americans take a nap every day, but 39% of UNemployed Americans do too. (5)

Is drinking during pregnancy bad for the baby?
Children born to light drinkers (1-2 drinks a week) were less likely than children born to abstainers to have behavioral problems at 5 years of age and more likely to have higher vocabulary and picture similarity scores. (6)

What about drinking if you are diabetic?
According to “Healthy Eating for Type 2 Diabetes” published by Harvard Medical School, drinking alcohol reduces the risk of diabetes by up to 43%.  It also states that drinking coffee reduces the risk of diabetes by 42%. It does NOT endorse the newly popular Red Bull and vodka cocktails. (7) It does go on to say that losing 10% of your weight is really the best way to reduce your risk of diabetes.

Fishing is more dangerous than being a fireman or policeman.
The U.S. Department of Labor 2009 statistics of fatal occupational injuries per 100,000 full-time workers showed a rate of 200 for “fishers and related fishing workers” and a rate of 13.1 for police and 4.4 for firemen. Non-fatal injuries or illnesses per 10,000 civilian workers that resulted in lost days of work averaged about 117. The police rate of 676 and the firemen’s rate of 512 were soundly topped by the bus driver’s rate of 892. (8)

What’s the cure for the common cold?
Echinacea ain’t it. (9)  Zinc might be. Use of zinc lozenges within the first 24 hours of symptoms reduced the duration of cold symptoms from 7 to 4 days and reduced coughing from 5 to 2 days. (10) BUT, different zinc remedies contain different dosages and different forms of zinc, and too much zinc by nasal inhaler can blunt your taste sense. 200 mg or more of Vitamin C daily will reduce cold symptoms in smokers or seniors, but it won’t prevent colds. (11)

My two favorite cold cures are:
The British cure – Take a cold shower, immediately go outside while still wet, and run around the house without any clothes on. You will probably get pneumonia and “any damn fool doctor can cure pneumonia.”
The Scottish cure – You need a four poster bed, a hat, and a bottle of scotch. Put the hat on the Southeast  corner post of the bed, sit on the bed, and sip scotch until you see two hats. Even if you are not cured, you won’t care.

Another cause of autism?
Researchers in California studied more than 300 preschool children with autism and found that their mothers were much more likely to live near a freeway, and just freeways not other major roads, when pregnant than 260 preschool children without autism. (12) The California real estate market has been hit hard enough without implicating every house within 300 meters of a freeway.

You’re not still worried about bad effects from H1N1 flu shots are you?
A study of nearly 90 MILLION doses of H1N1 vaccine given in China in 2009-2010 were associated with 11 cases of Guillain-Barre Syndrome (GBS, ascending nerve paralysis). That is a rate of 0.1 per million doses which is lower than the normally occurring or “background rate” in China. (13)

Kids getting dirty may reduce later asthma and eczema.
Two studies in Europe showed that kids living on farms developed less asthma and had less eczema than kids living in a city. The kids on the farms were exposed to more bacteria and fungus and to many more types of those two “germs” than the city kids, and that exposure could explain the difference in the asthma rates. (14)

Unintended consequences of the “hot stuff”.
In a study of a 2008 epidemic of food-borne illnesses involving 1500 people in 14 states, 30 out of 35 restaurants (86%) of the associated restaurants were Mexican restaurants. Common ingredients included jalapeno peppers, serrano peppers, and raw tomatoes. Believe it or not, the CDC researchers were able to trace back the peppers through Texas distributors  to just two farms in Mexico. (15)

Some cars are greener than people.
Researchers in physiology at the University of Milan, Italy found that four men jogging produced MORE carbon dioxide emissions than a hybrid car driving them the same distance. (16)

References:
1. Clin Infect Dis 2011 Jan 1; 52:23
2.JAMA 2011  Jan 5;305:50
3. Jour Watch Gen Med vol. 31 Feb. 1, 2011 p. 26
4. Boston Globe Jan. 22, 2010
5.Harpers Index September 2009 p. 13
6. J Epidemiol Community Health 2010 Oct 5
7. AARP Bulletin Nov. 2009 p.14
8. http://www.marketwatch.com, Ruth Mantell, Feb 2011
9. Ann Intern Med 2010 Dec 21;153:769
10. Jour Inf Dis March 2008, Meenu Singh, MD
11. Consumer Reports on Health March 2011 p.4
12. Environ Health Perspect 2010 Dec 13
13. NEJM 364;7 Feb 17, 2011
14. NEJM 364;8 Feb 24, 2011
15. NEJM 364;10 Mar. 10,2011
16. Scientific American May 2011 p.18



Vol. 42 April 1, 2011 Updates on Health Care Reform

March 31, 2011

“You can always count on Americans to do the right thing – after they’ve tried everything else.”
-Winston Churchill

Mitt Romney announces his candidacy for Governor of Massachusetts

Persistently harassed by Tea Party leaders and other conservative Republicans for the inclusion of the “individual mandate requirement” in his Massachusetts Health Care Reform Act and tired of defending it as “good for Massachusetts but not necessarily for [insert name of any state in which Romney is that day]”, Mitt Romney has announced that he will abandon his exploratory campaign for the Presidency. He will return to Massachusetts to run for Governor against Duval Patrick. “Since this annoying issue of the individual mandate just won’t go away, I am going back to Massachusetts to undo it,” said Romney.

Donald Berwick, MD apologizes to Congress for his extreme behavior during his hearing

Though most reviewers remarked on Dr. Berwick’s evenhanded responses to the sometimes hostile questioning at the Senate Finance Committee hearing on his nomination as CMS Administrator, this blogger has a different view. I was present in the hearing room just after the TV cameras and microphones were turned off. Dr. Berwick, having kept his cool for so long, literally exploded, cussing the senators for their “mean-spirited, narrow-minded, myopic views of the federal government’s role in health care”. “Arguing with you is like talking to a dinner table.” When this outburst hit You Tube via someone’s cell phone the next day, Dr. Berwick quickly apologized. “As a pediatrician I thought I knew how to control temper tantrums, but somehow that hearing just conjured up all the adolescent turmoil that I thought I had outgrown, and I flew off the handle. I am extremely sorry, but am very thankful that my staff took away my iPhone before I was able to tweet.”

President Obama was so shaken by Dr. Berwick’s outburst that he has begun seeking a replacement; one who has experience in public policy, is a strong individual, is acceptable to most Republicans, and who is currently unemployed.  Arnold Schwarzenegger springs to my mind, though he is rumored to have returned to acting, “I lift things up and then put them down.”

Sarah Palin withdraws her opposition to “Death Panels”

According to David Williams writing for the Health Care Blog: “Chief among Sarah Palin’s assaults on truth and reason is her contention that providing reimbursement for end-of-life planning sessions with a health care provider is tantamount to a “death panel” where a “bureaucrat can decide based on a subjective judgment of [a person’s] ‘level of productivity in society,’ whether they are worthy of health care.” One ingredient of end-of-life planning is patients’ opting for palliative care. He summarized a recent study in New York state where patients who received palliative care cost Medicaid almost $7000 less in hospital costs per admission than a matched control group that didn’t receive palliative care. Patients receiving palliative care spent less time in the intensive care unit and were less likely to die there. They were also more likely to receive hospice care after discharge and to be discharged to appropriate settings.

Impressed by this report and other studies, Sarah Palin has withdrawn her opposition to the reimbursement of  “Death Panels” to help patients and families plan for end-of-life care. However, her newly found acceptance of rational end-of-life care is tempered by the unintended consequence of the increased satisfaction of families receiving palliative care.  “Most people on Medicaid are unemployed, deadbeats, or probably illegal immigrants, so why should we be spending time and money increasing their satisfaction with our health care system?”

Starbucks will add Urgi-Care Centers to their stores

Howard Schulz, CEO of Starbucks, announced that as of April 1 they would be establishing urgent care counters in selected urban stores. He is impressed with the successful implementation and rapid growth of convenient medical service centers in CVS pharmacies and wants to remain competitive in the crowded field of one-stop-service retail stores. According to Schultz, “Starbucks is the quintessential experience brand and the experience comes to life by our people.  The only competitive advantage we have is the relationship we have with our people and the relationship they have built with our customers.”

Analysts remark that this move is consistent with Starbuck’s image as a “home away from home and work” where one can go to relax, listen to music, buy a CD, work on a computer, read a newspaper, eat a snack, trip over a stroller, smile at the dogs tied up outside the door, and …get a cup of coffee.

Schulz also announced that a new flavor shot, “Potassium Iodide”, will be introduced in selected West coast stores in response to recent consumer inquiries there. Despite the phenomenal growth of medical marijuana stores in California and Colorado, Starbucks has no current plans to add this to their offerings. “A double espresso mocha caramel Vente is as high as you can go at Starbucks for the moment.”

Congress to hold hearings on what to call the new medical care payment system

The Accountable Care Organizations (ACO) proposed by the Affordable Care Act (ACA) will require the replacement of fee-for-service provider payments with a collecting together of all kinds of medical care bills which will then be paid out of a single account. Congress has known for a long time that no one knows what “ACO” means, and now, no one seems to agrees on what to call this new billing and payment method. The CMS, GAO, AMA, AHA, and AAMC just issued issued a report of their study of possible labels and asked for congressional hearings on their conclusion. Here are selected samples of the rejected names and their recommended conclusion:

“fee-splitting”– Though functionally similar to ACO methods the AMA objected to this because of their successful, long time efforts of labeling it as unethical.

“capitation” (also called “capitation-light” or “neo-capitation”) – Again, though functionally very similar to the ACO method, it was felt that this word had too many negative political, economic, and patient-control associations.

“global payments” – This one was very popular and is still in use by some people, but the negative associations with the weird weather we are having and with Al Gore nixed it. The fact that “global” corporations seem to be very successful in  avoiding anti-trust litigation was a definite plus for this label.

“rational budget allocation” – Sounded too much like the U.K. National Health Service,  definitely requires the advance planning dreaded by most physicians, and the  second word was the only one with a meaning accepted by all.

“single payment to all medical providers for a patient’s illness for life” (SPAM PILL)- An accurate statement, but much too long for an acronym or sound bite, and though the acronym implies a use of electronic networking (good), it has an  annoying connotation (bad).

After many meetings, exhaustive staff work, and numerous drafts of over 100 pages each the report finished with this final conclusion:

‘The one word that captures the collective nature of the new payment system with both warm, fuzzy connotations and a positive image is ‘bundling’, as in the soft, warm bundling of a baby in a blanket. Who could be threatened by that?”

HAPPY APRIL FOOLS DAY


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